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Incremental Adjustments to Amount of Thickening Agent in Beverages: Implications for Clinical Practitioners Who Oversee Nutrition Care Involving Thickened Liquids

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Incremental Adjustments to Amount of Thickening Agent in Beverages: Implications for Clinical Practitioners Who Oversee Nutrition Care Involving Thickened Liquids foods Article Incremental Adjustments to Amount of Thickening Agent in Beverages: Implications for Clinical Practitioners Who Oversee Nutrition Care Involving Thickened Liquids Jane Mertz Garcia 1,* and Edgar Chambers IV 2 1 Communication Sciences & Disorders, School of Family Studies & Human Services, Kansas State University, 1405 Campus Creek Road, Manhattan, KS 66506, USA 2 Center for Sensory Analysis and Consumer Behavior, 1310 Research Park Dr., Manhattan, KS 66502, USA; [email protected] * Correspondence: [email protected]; Tel.: +1-785-532-1493 Received: 3 January 2019; Accepted: 12 February 2019; Published: 14 February 2019 Abstract: This study examined the changes in viscosity in response to small alterations in the amount of a thickening agent mixed with three commonly thickened beverages. A total of 11 incremental adjustments in the amount of a starch-based thickening agent (5.0 g to 7.0 g) were made. The results showed that the incremental increases resulted in systematic changes to the liquid thickness, reflecting modifications that ranged from a nectar (mildly thick) to a honey-like (moderately thick) level of consistency. The findings emphasize the importance of the proper preparation of thickened beverages, highlighting the need for standards in training practices and the use of simple measurement tools for assuring the prescribed levels of consistency. Keywords: dysphagia; swallowing; thickened beverages; liquids; viscosity; quality of care 1. Introduction The nutritional care of patients with dysphagia who consume thickened beverages requires the careful preparation of drinks to their prescribed level of modification. Basic care staff (e.g., dietary aides, cooks, and certified nursing assistants) are typically tasked with preparing modifications even though they reportedly receive little or no formal instruction about thickened liquids [1,2]. Although a number of modified beverages are currently available in ready-to-serve form, thickening liquids with commercial thickeners that require preparation by caregivers are a cornerstone of nutrition care in many settings [3,4]. One practical concern about the preparation of thickened beverages is the lack of adherence to product guidelines when determining the amount of thickening agent to mix into a beverage. Garcia et al. [2] found that many of the care staff did not look at the product label information to determine the specified amount of thickening agent. Unsurprisingly, the modifications they prepared varied considerably in terms of measured viscosity when compared to similar product/beverage combinations made in a laboratory environment using controlled conditions [2]. Even speech-language pathologists (who are experienced in dysphagia management) have difficulty preparing thickened beverages in a reliably consistent manner [5]. This inability to prepare thickened liquids consistently is a cause for concern because of the health implications linked to over- or under-thickening the beverage of patients. Clinical practitioners are encouraged to recommend the least viscous modification that is swallowed safely, which further magnifies the importance of careful preparations [6–8]. Inaccuracies Foods 2019, 8, 74; doi:10.3390/foods8020074 www.mdpi.com/journal/foods Foods 2019, 8, 74 2 of 7 in preparation increase the risk of additional medical complications. For example, overly thickened beverages are more difficult for frail elders to clear from their airway, heightening the risk of pulmonary complications or aspiration pneumonia [9]. Such problems may occur in patients with impaired swallowing or a diminished ability to cough. Overly thick modifications also contribute to post-swallow residues in the pharynx [7,8]. Because the addition of a thickening agent affects the flavor and texture of a drink in a potentially negative way [10,11], caregivers who routinely overly thicken may create a modification that impacts the beverage’s acceptance. Patients with a strong dislike of the thickened beverages may, as a result, be less compliant and drink less, ultimately impacting their nutritional status. This occurs through a decreased consumption of juices, liquid nutritional supplements and other beverages. Additionally, a reduced consumption of beverages also can contribute to other medical complications such as dehydration, especially if water the consumption decreases. Although the concern regarding preparation inaccuracies is clear, less is known about how small variations in the amount of thickening agent impact physical measures of viscosity. Park et al. [12] already evaluated various levels of gum-based thickeners, both guar and xanthan, showing that the viscosity of guar gum thickened liquids changed more rapidly than that of xanthan gum as the concentration increased, perhaps because of shear thinning. Such results suggest that in some cases inadvertent changes in thickening, such as might occur when beverages are mixed improperly, could result in large changes in viscosity. Because no work has been found examining incremental changes in starch-based thickeners, the goal of this study was to understand how incremental changes in the amount of starch-based thickening agents contributed, if at all, to viscometer readings for different modified beverages. 2. Materials and Methods We selected Thick & Easy (Hormel Health Labs, Austin, MN, USA), a commercial thickening agent commonly used in modifying liquids for patients with dysphagia. The product ingredients listed modified corn starch and maltodextrin. The three beverages included water, apple juice (Musselman’s, Peach Glen, PA, USA) and cran-apple juice, a commercial blend of apple and cranberry juice (Ocean Spray, Lakeville-Middleboro, MA, USA). The beverages represented common drinks in care facilities that are easily mixed (no clumping) with a thickening agent. All have quite a low viscosity (cps 0–2). It must be noted that for this project a variety of samples could have been selected. We intentionally chose to keep the study small and focus on one thickener, a starch-based product that is widely used in dysphagia management in the United States. Gum-based thickeners are also widely used, but typically they are more difficult to mix, and this would present an added variable to this study. In addition, Park et al. [12] already evaluated various levels of gum-based thickeners. 2.1. Sample Preparation Procedure The volumetric amount of liquid (120 mL) was converted into grams to ensure the same amount of beverage for each sample. The amount of thickening agent (also measured in grams) was slowly poured and stirred into the base liquid at room temperature (20–22 ◦C) and then continuously stirred for 40 s until it dissolved using a Barnstead Thermolyne magnetic stirring device (Cimarec 2) set to a constant speed. We systematically increased the amount of thickening agent by 0.2 g (e.g., 5.0 g, 5.2 g, 5.4 g, and 5.6 g) in each subsequent test sample. An increase of 0.2 g equated to slightly less than a 1mL (1/8 tsp) measuring spoon difference of thickening agent. Three separate samples were prepared for 11 incremental changes in thickening agent (5.0 g to 7.0 g) across beverages. The lowest to highest amount of instant thickening agent (a difference of 2.0 g) represented a difference of about 1 7.5 mL (by volume) of powdered thickener (equivalent to about 1 2 tsp, a common measure in the US). The thickness ranged from nectar-like (mildly thick) to honey-like (moderately thick), including the border of the two thickness levels (Figure1). Foods 2019, 8, 74 3 of 7 Foods 2019, 8, x FOR PEER REVIEW 3 of 7 1 Figure 1.FigureVisual 1. Visual comparison comparison of 5.0of 5.0 g (3g (32 ½tsp) tsp) and 7. 7.00 g (5 g (5tsp) tsp) of instant of instant thickening thickening agent. agent. 2.2. Viscosity2.2. MeasurementViscosity Measurement ViscosityViscosity was measured was measured using using a Brookfielda Brookfield RVDV- II+ II+ viscometer viscometer using usingthe small the sample small sample adaptor andadaptor calculated and calculated at a shearat a shear rate rate of of 55.8 55.8 toto be consistent consistent with with instrument instrument guidelines guidelines and and modification ranges described by the National Dysphagia Diet [13]. The samples were measured at modificationroom ranges temperature described (20–22 °C) by after the two National minutes Dysphagiaof thickening time. Diet The [13 measurements]. The samples were were collected measured at ◦ room temperaturefor a total of (20–22 99 samplesC) after(11 changes two minutesin gram amount of thickening × 3 beverages time. × 3 replicates). The measurements were collected for a total of 99 samples (11 changes in gram amount × 3 beverages × 3 replicates). 2.3. Statistical Analysis 2.3. Statistical AnalysisWe entered the data into the IBM SPSS System for Windows (IBM, New York, USA, Version 25, 2017); a “descriptive” statistics procedure was used to determine the means and standard deviations We enteredfor each thegram data amount into and the for IBM each SPSSbeverage System over the for three Windows replicates. (IBM, The gram New measurements York, USA, and Version 25, 2017); a “descriptive”physical measurements statistics of procedureviscosity of each was beverage used towere determine compared using the means Pearson and product-moment standard deviations for each gramcorrelation amount coefficients and for with each a significance beverage at overthe 0.01 the level three (2-tailed). replicates. The gram measurements and physical measurements3. Results of viscosity of each beverage
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